H - Data Items Chart

Attachment H: Data Items Chart

State Surveillance Under the National Toxic Substance Incidents Program

Event Identification tab

Question 1: Based on the NTSIP case definition, is the event eligible?

Question 2: Date the NTSIP staff were notified of the event

Question 3: Who first notified the state health department?

Description tab

Question 4: What was the date of this event?

Question 5: What time did this event start?

Event Location tab

Question 6: Where did the event start? Were multiple locations contaminated during this event?

Question 7: Was this a private vehicle or residence?

Question 8: Event location

Question 9: Is the location listed in Question 8 the same as the industry (or entity) that caused the hazardous substance release?

Question 10: Responsible Industry Name

Area/factors tab

Question 11: What is the general land use in the surrounding area?

Question 12: Factors contributing to the release

Transportation/fixed facility tab

Question 13: What type of event was this?

Question 14: What mode of transportation was involved?

Question 15: What phase of transportation was involved?

Question 16: What area/equipment of the fixed facility was involved in the event?

Question 17: Did the release impact a closed structure?

Substance tab

Question 18: Substance type/Name/Information

Question 19: Was the substance actually released into the environment or threatened to be released into the environment?

Question 20: Used as a pesticide?

Question 21: Type of Release

Question 22: Quantity Released

Question 23: Unit of Measure

Victims tab

Question 24: How many people were injured in this event?

Question 25A: Category of victim

Question 25B: Is the victim a certified HazMat technician?

Question 25C: Severity and disposition of victim

Question 25D: Adverse health effects

Question 25E: Personal Protective Equipment (PPE)

Question 25F: Age category of victim

Question 25G: Decontamination of injured person

Decontamination/Affected Population tab

Question 26: Total number of people decontaminated at the scene

Question 27: Total number of people decontaminated at the medical facility

Question 28: Did the event affect any of the following routes of transportation?

Evacuation and In-place Sheltering tab

Question 29: Did an evacuation occur?

Question 30: What is the total number of people evacuated?

Question 31: Did an official order in-place sheltering?

Question 32: Was access to the area restricted in any way?

Response tab

Question 33: Activities taken to protect the public health as a result of this event?

Question 34: Who responded to this incident?

Comments and Synopsis tab

Question 35: Are there any comments on the data collection form?

Question 36: Enter a brief synopsis of the event with pertinent information.